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To the Editor:-A group of articles in the May 1997 issue provide solid background to explore the difficult micro- and macro-economic issues that lie ahead for physicians and anesthesiologists. The view of medicine as a profession and industry is rapidly evolving. In Dr. Shapiro's words, the practice of medicine is no longer “a risk-free economic enterprise completely independent of marketplace forces.”[1 ] Corporate America and our society in general have required that standard principles of economics be applied, sometimes abruptly, to health care. Managed care has thrived in this environment. Are physicians and society prepared and willing to deal with the ethical and financial dilemmas that will arise from the full application of marketplace forces to the nation's health care industry?

Today, the public expects to receive the best possible anesthetic care at little or no personal financial cost. For them, optimal care translates into well-trained board-certified anesthesiologists applying high-tech monitoring, performing skill-intensive techniques, and administering the newest drug in the market. A basic rule of the marketplace is that quality and cost are intimately related. Are the public and the governmental agencies, state and federal, entrusted with overseeing and financing health care delivery, prepared to accept that the quality of the anesthetic service (degree of postoperative pain relief, incidence of side effects, and likelihood of significant complications) would depend on the payment amount? Are anesthesiologists ready to embark in such an enterprise? Should an anesthesiologist consider the expected reimbursement for the hospital and him or her while finetuning the anesthetic plan? Would we uphold the Hippocratic Oath then? Certainly, society cannot expect to ignore these difficult issues while some sectors amass the financial benefits of the initial application of the principles of economics.

Another basic rule of free market economics is that the consumer is the recipient of the goods or services and the payer of the product. This tenet is of paramount importance in achieving maximum efficiency in the capitalist system. The consumer selects the product depending on his or her perception of quality and value. This perception is based on factual information, past experience, recommendations, and marketing. In a true free market, the intersection of the supply and demand curves dictates the market price of the service, i.e., the anesthesiologist's professional fee.

Our current system leads to inefficiency because the patient is the recipient of services, but not the buyer. The government is the buyer for the Medicare and Medicaid programs. The government sets the reimbursement rates based on budgetary considerations and HCFA recommendations. For most employed people, the insurance carrier is selected by the employer. This decision is based on the cost of the plan, not necessarily its quality. This arrangement excludes the recipient of services from the decision-making process of selecting an insurer, and by association, a provider. The only way to seek an efficient free market is to transfer the buying decision to the direct consumer, the patient.

I fully understand the dogma of “It's Original Investigations, Doctor,” as presented by Dr. Shapiro. But are we as a profession and as society prepared to apply the full weight of economics to the health care market? How far are we from asking our clients:“Which anesthesia service would you like to book-coach, business, or first class?”